CHAPTER
75
Radiographic Classification Scheme:
Lenke Classification
INTRODUCTION
Clinical researchers have sought to classify adolescent idio-
pathic scoliosis (AIS) to allow grouping of similar curve pat-
terns, recommend treatment guidelines, and to compare
surgical outcomes. For more than 20 years, the King-Moe clas-
sification of thoracic AIS, published in 1983,6 was the first
broadly applied classification system in the era of instrumented
spinal fusions. Although somewhat limited in that it solely ana-
lyzed thoracic curves and addressed only coronal plane defor-
mity, it did provide excellent treatment recommendations in
the Harrington instrumentation era. These guidelines included
the use of the stable vertebra in the selection of distal fusion
levels, the performance of selective thoracic fusions in appro-
priate King II (false double major [DM]) curve types, and the
recognition of a double thoracic (DT) curve pattern (King V)
to optimize shoulder balance when treating a major thoracic
scoliosis. Although the system is still utilized by many practitio-
ners, it was shown to have only fair inter- (Kappa 0.4) and
intraobserver (Kappa 0.62) reliability by two separate studies
published simultaneously in 1998.11,24
As a response to the shortcomings of this system, in 2001
Lenke and colleagues published a more comprehensive AIS
classification system (Table 75.1).15 This system has become uti-
lized throughout the world as a reliable system using biplanar
radiographs to separate curves into a modular triad classifica-
tion system. The reliability of this system was found to be supe-
rior to the King system when analyzing the same set of radio-
graphs, with Kappa values of 0.92 for interobserver reliability
and 0.83 for intraobserver reliability.11 This chapter will discuss
the Lenke Classification System of AIS emphasizing curve anal-
ysis, treatment recommendations, and fusion level selection. It
is not applicable to adult scoliosis or nonidiopathic conditions.
RADIOGRAPHIC COMPONENTS OF THE
CLASSIFICATION SYSTEM
Four standard preoperative radiographs are necessary to clas-
sify operative AIS patients by this system. These include upright
long cassette coronal and sagittal (anteroposterior and lateral)
radiographs as well as right and left supine side-bending radio-
graphs. On the upright coronal radiograph, Cobb measure-
ments are derived for the proximal thoracic (PT), main thoracic
(MT), and thoracolumbar/lumbar (TL/L) regions (Fig. 75.1).
738
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Lawrence G. Lenke
An MT apex includes T3 distal to the T11-T12 disc, while a
TL/L apex including the T12-L1 disc distal to L4. The major
curve is the largest Cobb measurement (the MT curve will
default as major if the MT and TL/L curves are identical in
Cobb measurement or in the rare circumstance when the PT
curve is major), and the other two regions will be designated as
minor curves. Minor curves are divided into structural and
nonstructural. Minor curve structural criteria are derived from
side-bending radiographs and the long cassette lateral radio-
graph. On side-bending radiographs, a residual Cobb measure-
ment of 25 or greater designates a minor curve as structural,
while those measuring 25 are nonstructural. In addition, the
PT (T2-T5) and TL junction (T10-L2) sagittal Cobb measure-
ment is obtained. When the PT or TL/L kyphosis is 20 or
greater, then those regions are designated as structural minor
curves regardless of what the side-bending coronal plane radio-
graphs measured.
Two modifiers are also described in this classification system,
the coronal lumbar and sagittal thoracic. For the coronal lum-
bar modifier, on the upright coronal radiograph a center sacral
vertical line (CSVL) is drawn bisecting the sacrum and extend-
ing vertical to the TL junction. Coronal lumbar modifier A is
designated if this line lies between the pedicles at the apical
level, coronal lumbar modifier B is designated if that line
touches the apical vertebral pedicles, and coronal lumbar mod-
ifier C is assigned if the line is completely off the apical verte-
bral body and pedicles (Fig. 75.2). The sagittal thoracic modi-
fier is selected from the long cassette lateral radiograph. The
T5-T12 sagittal alignment is designated as or hypokyphotic
(10), N or normokyphotic (10 to 40), or or
hyperkyphotic (40).
Following these radiographic analyses, the triad Lenke
Classification System can be produced. This system first
describes six curve types depending on the location of the
major curve (major curve in the thoracic spine for types 1, 2, 3,
and 4) or TL/L spine (types 4, 5, and 6), along with the struc-
tural nature of the minor curves, which then distinguishes the
six individual curve types (Table 75.2). Next, the coronal lum-
bar modifier A, B, or C is added based on the above-mentioned
relationship with the CSVL to the apex of the lumbar curve.
Lastly, the sagittal thoracic modifier , N, or is added based
on the T5-T12 sagittal Cobb measurement. In combination,
this triad classification system (e.g., curve classification 1AN) is
produced. Although there are a total of 42 separate curve
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 Chapter 75 Radiographic Classification Scheme: Lenke Classification
TABLE 75.1 Curve Types (1 to 6)
Curve Type PT MT TL/L
1 NS S NS
2 S S NS
3 NS S S
4 S S S
5 NS NS S Thoracolumbar/lumbar (TL/L)
6 NS S S
NS: nonstructural; S: structural.
classifications possible, when one uses the modularity of this
system and determines the curve type (1 to 6), coronal lumbar
modifier (A, B, or C), and sagittal thoracic modifier (, N, or
) then joins them together, this system is much more user-
friendly and easy to understand.
While this radiographic classification system is fairly descrip-
tive, because of the thorough radiographic analysis performed,
there are certainly many additional factors that play an
extremely important role in deciding on the actual regions of
the spine to fuse as well as determining specific fusion levels.14
Simplistically, the treatment guidelines of the Lenke system rec-
ommend that one should consider fusing the major curve as
well as the structural minor curve(s) but not the nonstructural
minor curve(s). However, there are other aspects of the radio-
graphic and clinical presentation that are important in this
decision process. These factors include the ratio of radio-
graphic parameters, the level of skeletal maturity, preoperative
shoulder alignment, thoracic and lumbar prominences, trunk
balance, athleticism of the patient, and personal desires and
wishes of the patient.20 Thus, in combination with this classifi-
cation system these various additional radiographic and clinical
factors, as well as the prior operative experience of the surgeon
Figure 75.1. Anteroposterior and lateral X-rays demonstrating the
proximal thoracic, main thoracic, and the thoracolumbar/lumbar
regions.
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739
Description
Main thoracic (MT)
Double thoracic (DT)
Double major (DM)
Triple major (TM)
Thoracolumbar/lumbar-main thoracic
(TL/L-MT)
help guide the surgeon to appropriate surgical decisions for
patients with operative AIS.
CURVE TYPES
Curve Type 1
In type 1 MT curve patterns, the major curve is in the MT
region and the PT and TL/L regions are nonstructural
minor curves (Fig. 75.3). Thus, the suggested treatment is
anterior or posterior correction and fusion of the MT region
only. In the past 10 years, the use of an anterior spinal fusion
(ASF) approach for a type 1 MT curve has diminished sig-
nificantly at our institution and throughout North America.1,12
Simultaneous with this, there has been an increased use of
posterior spinal fusion (PSF) procedures with pedicle screw
instrumentation.9,21,10 The upper instrumented vertebra
(UIV) is typically T3, T4, or T5, while the lowest instru-
mented vertebra (LIV) will vary considerably between T11
(rarely) and L4 or even L5-sacrum (rarely).
Correction maneuvers of type 1 MT curves include a variety
of options such as cantilever, in situ contouring, in situ transla-
tion, apical derotation using pedicle screws, and selective com-
pression and distraction forces applied in an attempt to maxi-
mally translate the apex and horizontalize the LIV when
appropriate. In the pedicle screw era, the use of apical derota-
tion maneuvers has become common with subsequent improve-
ment of rib prominences obviating a thoracoplasty procedure
in the majority of patients.9 For those patients who have a severe
apical lordotic component to their curve, the use of ligament
releases or formal periapical Pont or Smith-Petersen osteoto-
mies may be necessary to improve this sagittal plane malalign-
ment thereby restoring a more physiologic kyphosis across
these apical segments. Also, in large and stiff deformities
(upright coronal Cobb 75, with side bending 50), these
apical releases will be helpful to allow maximum correction
while minimizing the bone/screw interface stresses during
correction.22
Advantages of Lenke et al
TABLE 75.2
Classification System of AIS
Comprehensive
Two-dimensional
Reliable
Modular (curve type, lumbar, and sagittal modifiers)
Treatment recommendations (fuse major and structural
minor curves)
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 740 Section VII Idiopathic Scoliosis
Figure 75.2. Coronal lumbar spine
modifiers A, B, and C are depicted
based on position of the apex of the
lumbar curve to the center sacral
vertical line.
The selection of the LIV is strongly correlated with the coro-
nal lumbar modifier. For coronal lumbar modifier A curve pat-
terns, the LIV selected is usually the most cephalad vertebra in
the TL/L region that is at least intersected by the CSVL on the
upright coronal radiograph and is neutral in rotation (Case
75.1). This typically is one-level caudad to the lower end verte-
bra (LEV) of the MT curve and one or two levels cephalad to
the true stable vertebra. For coronal lumbar modifier B curve
patterns, this same rule for the LIV seldom holds true. Typically,
the last vertebra touched by the CSVL is a safe LIV selection as
1A 1B
Figure 75.3. Schematic drawings of type 1A, 1B, and 1C main tho-
racic (MT) curve patterns. General rule: posterior spinal fusion/PSSI
or anterior spinal fusion/ASSI MT curve only.
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long as there is no TL junctional kyphosis present. However, for
coronal lumbar modifier C curves, the stable vertebra (typically
T11, T12, or L1) located in the TL junction is selected as the
LIV when a selective thoracic fusion is performed.
The type 1C curve pattern is highly controversial.2 Even
though the TL/L region completely deviates off the CSVL at
the apex, the TL/L curve side bends to less than 25 and lacks
a true junctional kyphosis. Thus, a selective thoracic fusion is
recommended for most 1C curves. However, the selection of
patients with a 1C curve pattern suitable for a selective thoracic
fusion will necessitate additional evaluation beyond the Lenke
Classification System.23 Analysis of radiographic and clinical
ratios of the thoracic to the lumbar spine deformity is also
imperative.18 In this regard, evaluating the ratio of thoracic to
lumbar Cobb measurements, apical vertebral rotation (AVR),
and apical vertebral translation (AVT) is performed. When
these ratios are greater than 1.2 and ideally close to 2.0, espe-
cially the AVT ratio, then a selective thoracic fusion can typi-
cally be successfully performed (Table 75.3). In addition, it is
necessary to evaluate the patients upright, prone, and forward
bend clinical posture in order to document that a thoracic
lumbar clinical prominence is present. In the suitable patient,
typically a thoracic trunk shift will outweigh any lumbar shift
Radiographic and Clinical
TABLE 75.3 Parameter When Considering
a Selective Thoracic Fusion
Curve Types 1C, 2C, 3C, 4C
Cobb Measures: Thoracic to lumbar ratio should be 1.2
AVT Thoracic to lumbar ratio should be 1.2
AVR Thoracic to lumbar ratio should be 1.2
1C
Absence of thoracolumbar kyphosis: 10 T10-L2
Scoliometer measures: Thoracic to lumbar and a 1.5 ratio
Absence of waistline asymmetry due to lumbar curve translation
Absence of connective tissue disorders
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 Chapter 75 Radiographic Classification Scheme: Lenke Classification 741

manifested by an absent waistline crease. On forward bending,

a scoliometer evaluation will demonstrate a greater thoracic
than lumbar thoracic prominence. On prone positioning, the
thoracic deformity should overpower any lumbar deformity,
which often becomes barely noticeable. A preoperative supine
or prone coronal radiograph will document the greater struc-
tural nature of the thoracic versus lumbar curve. In addition,
there should be no obvious junctional kyphotic deformity
between the two regions. These same analyses can even be
applied to select 3C and 4C curves that may be candidates for a
selective thoracic fusion (Case 75.2). Ultimately, we operate on
the patient not the radiographs and thus the clinical examina-
tion must be an important component to the evaluation of any
patient with scoliosis undergoing surgery, and especially those
undergoing selective fusion (Table 75.3).3
An ASF with instrumentation of the MT curve from the
upper end vertebra (UEV) to the LEV can be an acceptable
treatment method, especially for those with a (hypokyphotic)
sagittal thoracic modifier. However, this procedure is performed
infrequently due to adverse pulmonary function effects from an
open thoracotomy, and the technical challenges adherent to
2A 2B 2C
the endoscopic approach.4,17 When treating 1C curve patterns
posteriorly using a hybrid or pedicle screw construct, it is impor-
Figure 75.4. Schematic of type 2 double thoracic curves with 2A,
tant to undercorrect the curve in the coronal plane to allow har-
2B, and 2C represented. Shaded vertebrae correspond to apical verte-
monious alignment to the unfused lumbar curve below. One brae in relation to center sacral vertical line. General rule: posterior
advantage of utilizing pedicle screw constructs in 1C (or 2C, 3C, spinal fusion/PSSI including both proximal thoracic and main tho-
or 4C) curve patterns undergoing selective fusion is the ability racic curves.
to perform an apical derotation maneuver with pedicle screws
to correct the rib prominence while still undercorrecting the
coronal plane deformity. It is also important to leave a fair or T3. On rare occasions, the UIV can be as low as T4 or even
amount of residual tilt to the LIV to accommodate the unfused T5 if the right shoulder (for a typical left PT, right MT curve
lumbar region below. Careful analysis of the sagittal plane is also pattern) is elevated preoperatively, thus rebalancing the shoul-
important to make sure that a subtle TL/L junctional kyphosis ders while avoiding fusion of the PT region.8 However, one
will not become aggravated if ending the fusion at the TL/L must be careful that the left shoulder does not become elevated
junction. Therefore, while there are many pitfalls to performing following surgery, and the PT sagittal alignment is acceptable.
a selective thoracic fusion in various C curve patterns, doing so
certainly minimizes fusion levels while maximizing postopera- Curve Type 3
tive lumbar motion, and appears well worth the analysis and
treatment when successfully performed. A type 3 DM curve consists of a major MT region with a struc-
tural TL/L region and a nonstructural PT region (Fig. 75.5).
Thus, recommended operative treatment will require instru-
Curve Type 2
mentation and fusion of both the MT and TL/L regions
Type 2 DT curves have the MT region as the major curve, a through a PSF approach for most of those curve patterns. The
structural PT region but a nonstructural TL/L region (Fig. UIV is similar to that of a type 1 curve, typically beginning at
75.4). The recommended treatment is a PSF of both the PT T3, T4, or T5 based on the radiographic and clinical factors of
and MT regions. The UIV typically will be T2 or sometimes T3 a nonstructural PT curve and clinical shoulder alignment. In a
depending on the preoperative clinical shoulder alignment, typical 3C curve pattern that is not a candidate for a selective
while the LIV can be chosen in a similar fashion as described thoracic fusion, the LIV will usually need to be extended to
for type 1 MT curves. In selecting the UIV, the clinical position either L3 or L4. The decision to stop at L3 versus L4 is quite
of the shoulders is extremely important.7,19 If the left shoulder complicated and controversial.5,16 Typically all convex discs
if high (for a right MT curve) preoperatively, it is almost imper- needed to be included in the fusion; thus, if the L3-4 disc is
ative to start the construct at T2 (some authors advocate even open on the convexity then L4 must be chosen. Conversely, if
T1) to minimize further shoulder elevation or ideally level the the L3-4 disc is closed (concave) on the convexity of the TL/L
shoulders during operative correction (Case 75.3). This is per- curve, often L3 can be chosen as long as enough apical transla-
formed by applying compression forces on the convex side of tion to the TL/L region can be obtained to centralize and
the PT curve and distraction forces on the concave side. Pri- horizontalize L3. When the L3-4 disc is parallel on the preop-
marily, the PT sagittal alignment will dictate the application erative upright coronal radiograph, this analysis becomes even
and sequence of these forces. Typically, there is a hyperkyphotic more complicated. One must look at such factors as the amount
PT region in the sagittal plane that will benefit from convex of rotation present on the L3 vertebra, the distance of L3 from
compression forces applied prior to concave distraction forces. the CSVL, the distance of L3 from the apex of the TL/L curve,
When the shoulders are fairly level preoperatively, the goal is to the overall size (Cobb magnitude) of the curve, the amount
maintain normal shoulder balance usually having a UIV of T2 of residual lumbosacral deformity as reflected by any fixed

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 742 Section VII Idiopathic Scoliosis
3A 3B 3C
Figure 75.5. Schematic of type 3 double major curves with 3A, 3B,
and 3C represented. General rule: posterior spinal fusion/PSSI span-
ning both main thoracic and the thoracolumbar/lumbar curves.
wedging of the L3-4 disc or translation of L3 off the CSVL,
centering of L3 on a push-prone and/or side-bending radio-
graphs, and presence of an L5 and/or S1 fixed obliquity. These
radiographic factors will all play a role in the success of stop-
ping at the L3 level in these curve patterns (Case 75.4).
Most type 3 DM curves are associated with a lumbar C modi-
fier; however, those that have a lumbar A or B modifier usually
have an extremely large MT curve angle, which makes the
residual TL/L curve structural on side bending but not as
translated from the CSVL. Alternatively, TL/L junctional
kyphosis of 20 or greater creates a type 3 DM curve pattern
even when the coronal flexibility would predict a nonstructural
TL/L region as in a 1C pattern. Occasionally, there are 3C pat-
terns that one may consider for a selective thoracic fusion.2
When applying the radiographic and clinical ratio criteria as
described for a 1C pattern, if the ratios are favorable, one may
treat the larger thoracic radiographic and clinical deformity
leaving the lumbar curve unfused. However, one must carefully
select these rare 3C curve patterns for a selective thoracic
fusion, and perform appropriate instrumentation techniques
to allow optimal coronal and sagittal alignment and clinical
posture postoperatively (see Case 75.2).
Curve Type 4
A type 4 triple major (TM) curve has a major curve in the MT
or TL/L region with the other two regions including the PT
region structural minor curves (Fig. 75.6). Thus, these rare
curves typically require that all three regions PT, MT, and TL/L
be included in a PSF procedure. The UIV is selected in accor-
dance with the rules of the type 2 DT curve pattern, while the
LIV is selected in accordance with the rules of the type 3 DM
curve pattern. Thus, this curve pattern usually requires an
extremely long instrumentation and fusion from T2 or T3 down
to L3 or L4. However, just as mentioned in the previous three
curve types, selecting the major curve for isolated treatment and
leaving one or both of the minor curve(s) unfused may be
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4A 4B 4C
Figure 75.6. Schematic of type 4 triple major curves with 4A, 4B,
and 4C represented. General rule: posterior spinal fusion/PSSI all
three structural curves (proximal thoracic, main thoracic, and the
thoracolumbar/lumbar).
performed if radiographic and clinical conditions will allow for
a shorter fusion.
Curve Type 5
A type 5 TL/L curve pattern has the major curve located in the
TL/L region with nonstructural PT and MT regions (Fig. 75.7).
Thus, this single curve pattern can be treated with an isolated
ASF or PSF in the TL/L region. Traditionally, our institution has
treated these curves anteriorly, most recently with a dual rod5
instrumentation construct from the UEV to the LEV of the
TL/L curve (Case 75.5). However, as we and others are finding,
a PSF over the same instrumentation levels can often be per-
formed using pedicle screw instrumentation and apical derota-
tion maneuvers. The choice between an ASF and PSF is currently
controversial, but the use of segmental pedicle screw fixation is
imperative if one chooses a posterior approach for these curves
to try to obtain the same amount of correction and positioning
of the UIV and LIV as with an anterior procedure. Technically,
the goal is usually to horizontalize the LIV and potentially keep
some residual tilt to the UIV based on the amount of scoliosis
deformity present in the thoracic spine. This is analogous to the
performance of a selective thoracic fusion where the residual tilt
is left on the LIV of the MT curve. It is also imperative to evalu-
ate the nonstructural MT curve radiographically and clinically,
for in some circumstances it will be required to treat the tho-
racic curve even in a 5C pattern. Typically, the rib prominence
in the thoracic region, a junctional kyphosis between the MT
and TL/L curves, and/or shoulder malalignment may necessi-
tate including the thoracic curve as well.
Curve Type 6
A type 6 TL/L-MT curve has the major curve in the TL/L
region, with a structural MT curve, but a nonstructural PT
curve (Fig. 75.8). Both regions are treated with a PSF similar to
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 Chapter 75 Radiographic Classification Scheme: Lenke Classification
5C
Figure 75.7. Schematic of a type 5 thoracolumbar/lumbar (TL/L)
curve with a 5C curve pattern depicted. General rule: anterior spinal
fusion/ASSI or posterior spinal fusion/PSSI TL/L curve alone.
a type 3 DM curve pattern. In rare circumstances, a selective
TL/L fusion can be performed based on the structural criteria
comparing the TL/L region with the MT region. Thus, the
ratio of TL/L to MT Cobb measurement, AVR, and AVT as well
as the clinical deformity will show a definite larger TL/L defor-
mity.5 In this circumstance, a selective TL/L fusion can be per-
formed either anteriorly or posteriorly as described above.26
Occasionally, any of the curve patterns may be associated with
extremely large Cobb angles of the MT or less commonly TL/L
region. Because of the large major curve, the other minor curves
become structural based on sheer curve magnitude alone due to
residual Cobb measurements of greater than 25 on side bend-
ing. Currently these large and stiff curves are treated with multi-
level posterior-based osteotomies or even three-column osteoto-
mies such as a pedicle subtraction or a vertebral column resection
procedure (Case 75.6). These procedures are technically chal-
lenging and should be performed by scoliosis surgeons who are
comfortable treating severe deformities. These posterior osteot-
omy procedures have provided safe and optimal deformity cor-
rection without any formal anterior approach. However, we still
utilize preoperative halo-gravity traction for thoracic-based defor-
mities to aid in safely stretching the spine and chest wall thereby
improving pulmonary function as well.
SUMMARY
The use of the Lenke Classification System of AIS has provided
a template for analysis of the radiographic component of sco-
liosis, as well as basic treatment guidelines with respect to the
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743
6C
Figure 75.8. Schematic of a type 6 thoracolumbar/lumbar (TL/L)-
main thoracic (MT) curve with a 6C curve pattern depicted. General
rule: posterior spinal fusion/PSSI both curves (MT and TL/L).
regions of the spine to be included in the instrumentation and
fusion.20 However, it must be stressed that personal experi-
ence, additional radiographic analysis, and the patients clini-
cal deformity are extremely important in this decision process
as well. In addition, the level of skeletal immaturity plays an
important role in the operative approach and the LIV selec-
tion process as adding-on and crankshaft are adverse clinical
outcomes that should be avoided. It is well accepted that selec-
tion of the UIV and LIV as well as the performance of specific
intraoperative correction maneuvers in various sequences are
highly individualistic among surgeons and are part of the art
of scoliosis surgery.13,25 Because of the wide variety of fusion
levels chosen and techniques utilized to correct these spinal
deformities it is necessary to have a classification system that
allows outcomes assessment of similar curve patterns treated
differently. Thus, for the specific curve patterns described by
this classification system, various treatment methods can thus
be compared via multicenter analysis in order to eventually
select the optimal treatment of each specific curve pattern.
This will be important for not only radiographic assessment,
but also clinical assessment using outcome questionnaires such
as the Scoliosis Research Society (SRS) instrument as well as
functional assessments with pulmonary function tests, gait,
and range of motion analysis. Ultimately, multicenter analysis
of large numbers of similar curve patterns treated differently
should help sort out the best treatment of each particular
curve pattern, thus optimizing the surgical treatment of
patients with AIS.
Lastly, knowing that scoliosis is a three-dimensional (3D)
deformity, classifying AIS in three dimensions will be necessary.
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 744 Section VII Idiopathic Scoliosis

The SRS has a dedicated committee working on 3D curve anal- together. At that point, prospective analysis will provide assess-
ysis and potential classification of AIS. Hopefully in the future, ment of the 3D correction achieved with various surgical treat-
3D analysis for scoliosis patients will be the norm, and with a 3D ments to optimize these patients radiographic and clinical
classification system we will be able to group similar curves deformity postoperatively.

CASE EXAMPLES

CASE 75.1

(A) Patient is a 134-year-old girl with a 40 PT, 74 MT, and 42 TL/L curve. On left side bending, the PT
curve bends to 3 and the TL/L curve to 2, thus both are nonstructural. T5-T12 kyphosis is 25; therefore,
the curve classification is 1AN. (B) She was treated with a PSF with a pedicle screw construct from T4 to L2,
the lowest vertebra touched by the CSVL in the preoperative coronal radiograph. At 5 years postoperative,
there is excellent coronal and sagittal alignment. (continued)

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 Chapter 75 Radiographic Classification Scheme: Lenke Classification 745

C
(C) Pre- and postoperative upright and forward bend clinical photographs demonstrate the chest wall correc-
tion afforded by the pedicle screw construct with active derotation forces applied.

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 746 Section VII Idiopathic Scoliosis
CASE 75.2
B C
LWBK836_Ch75_p738-753.indd 746
(A) 146-year-old girl with a 27 PT, 68 MT, and 58
TL/L curve. On left side bending, the PT curve bends
to 16 and is nonstructural, while the TL/L curve bends
to only 38 and thus is structural. The T5-T12 kyphosis is
29; therefore, the curve classification is 3CN. (B)
Radiographic ratios of Cobb, AVT, and AVR are listed
with the AVT being the most important ratio showing a
2:1 difference in the apical translation of the
thoracic:lumbar curve. (C) Preoperative upright AP and
forward bend clinical photographs demonstrate the
overwhelming thoracic curve pattern versus the lumbar
curve pattern assessment. (continued)
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 Chapter 75 Radiographic Classification Scheme: Lenke Classification 747

(D) The patient underwent a PSF from T4 to L1 with a segmental pedicle screw construct and
undercorrection of the coronal curve down to the stable vertebra L1. At 3 years postoperative,
there is excellent coronal and sagittal alignment. (E) Postoperative clinical photographs dem-
onstrate the marked improvement of the trunk and chest wall following the selective thoracic
E fusion.

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 748 Section VII Idiopathic Scoliosis

CASE 75.3

(A) 158-year-old girl with a 59 PT, 66 MT, and

a 19 TL/L curve. On left side bending, the PT
curve bends out to only 50 thus the curve is
structural, while the TL/L curve bends to 6 and
is nonstructural. T5-T12 kyphosis is 30, thus the
curve classification is 2AN. (B) The patient under-
went a PSF from T2 to L3 with segmental pedicle
screws for realignment of both the PT and MT
curves. (C) Postoperative clinical photographs
demonstrate the nicely leveled shoulders with
improved trunk and rib cage alignment as well
C postoperatively.

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 Chapter 75 Radiographic Classification Scheme: Lenke Classification 749

CASE 75.4

B
(A) 158-year-old girl with a 25 PT, 60 MT, and 53 TL/L curve. On left side bending, the TL/L curve
bends out to only 25 and thus is structural. T5-T12 kyphosis is 7, thus the complete curve classification is
3C-. (B) The patient underwent a PSF from T4-L3 with segmental pedicle screw fixation. At 2 years postopera-
tive, the coronal plane LIV at L3 is completely horizontal, central, and neutral in position. In this case, a selec-
tive thoracic fusion was not performed due to the patients dissatisfaction with her waistline asymmetry preop-
eratively due to her lumbar translation.

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 750 Section VII Idiopathic Scoliosis

CASE 75.5

(A) 154-year-old girl with a 25 MT and a 53 TL/L curve.

On right side bending, the MT curve bends out to 16, thus
is nonstructural. T5-T12 kyphosis is 23, thus the com-
plete curve classification is 5CN. (B) The patient underwent
an ASF from T11 to L3 with dual anterior screw/rod system
and intervertebral cages. At 3 years postoperative, there is
marked realignment of the trunk with excellent position of
the LIV L3. (C) Pre- and postoperative clinical photographs
C demonstrate the marked trunk realignment.

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 Chapter 75 Radiographic Classification Scheme: Lenke Classification 751

CASE 75.6

A
(A) 165-year-old girl with an 80 PT, 138 MT, and a 60 TL/L curve. On left side bending, the PT curve
bends out to 65 thus is structural, while the TL/L curve bends to 22 and is nonstructural. T5-T12 kyphosis is
58, thus the complete curve classification is 2A. (continued)

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 752 Section VII Idiopathic Scoliosis

B
(B) (Continued) The patient underwent a PSF from T2 to L4 with a T10 posterior vertebral column resection.
Postoperative radiographs demonstrate marked correction of the coronal and sagittal planes. (continued)

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 Chapter 75 Radiographic Classification Scheme: Lenke Classification
C plasty performed.
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